Patient Evaluation of a Community Pharmacy ...

RESEARCH REPORTS Ambulatory Care

Patient Evaluation of a Community Pharmacy Medications Management Service Michela Tinelli, Christine Bond, Alison Blenkinsopp, Mariesha Jaffray, Margaret Watson, and Philip Hannaford, for the Community Pharmacy Medicines Management Evaluation Teama

any patients with chronic disease receive long-term drug therapy. Repeat prescriptions for these regimens in the UK can be considered equivalent to chronic use medications in the US. Their management has been the subject of critical review.1 The benefit of involving pharmacists in decisions about repeat medication has been demonstrated. For example, a randomized, controlled trial showed that, compared with usual care, pharmacists identified more drug interactions and adverse events and reduced drug costs.2 Enhancing the role of pharmacists has subsequently been incorporated into pharmacy strategies in all UK home countries.3-5 The new community pharmacy contracts, as well as other recent regulatory changes, have increased pharmacists’ contribution to the management of medications for chronic conditions in both community pharmacy and general practice settings. The UK’s National Health Service has adopted a rigorous, evidence-based approach to the introduction of new technologies, including new services. However, there have been few substantive,

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Author information provided at the end of the text. a

Community Pharmacy Medicines Management Evaluation Team listed in Appendix I.

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BACKGROUND:

A patient-centered approach is increasingly recognized as an important component in the evaluation of healthcare services.

OBJECTIVE:

To assess patient satisfaction with, attitudes toward, and expectations of or experience with community pharmacy in general, and to evaluate the effect of the community pharmacy–led medications management service on these factors.

METHODS: Postal questionnaire surveys were completed at baseline and after 12 months (follow-up) as part of a randomized controlled trial of the service. The setting was 9 primary care organizations in England. Patients with coronary heart disease were recruited from general practice registers and randomly allocated to the intervention (pharmacy-led medications management service) or control group. RESULTS: Survey response rates at baseline and follow-up were 88.4% (1232/1394) and 80.1% (1085/1355), respectively. The respondents indicated that they wanted pharmacists to provide dispensing, medications review, advice on medications and health, private consultation areas, and short visit times. At follow-up, intervention patients were more likely than control patients (p < 0.01) to rate the service provided by their pharmacist with a higher level of satisfaction, and most intervention patients stated a preference for seeing their physician to discuss their medications, although this was less marked than in control patients (76% vs 85%; p < 0.01). Intervention patients were also more willing than control patients to ask the pharmacist questions that they would be unable to ask a physician (20% vs 11%, respectively; p < 0.01), to ask the pharmacist questions about their medications (32% vs 18%, respectively; p < 0.01), and to recommend this practice to others (51% vs 40%, respectively; p < 0.01). CONCLUSIONS: Pharmacist intervention was associated with significant and positive changes in patient satisfaction. While patients probably continue to prefer a physician-led service, they value aspects of a pharmacy service. Patients generally preferred discussing medications with the family physician, but experiencing the community pharmacy–led service resulted in an attitudinal shift toward the pharmacist. These findings suggest a benefit in developing the community pharmacist’s role as a reviewer of, and adviser on, patients’ medications. KEY WORDS: community pharmacy services.

Ann Pharmacother 2007;41:xxxx. Published Online, xx XXX 2007, www.theannals.com, DOI 10.1345/aph.1K242

The Annals of Pharmacotherapy

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2007 December, Volume 41

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randomized, controlled trials published on the effects of medications management services led by community pharmacists. Our study, the Community Pharmacy Medicines Management Project, was a large, national, multicenter, randomized, controlled trial to evaluate the introduction of such a service for patients with coronary heart disease (CHD). The intervention consisted of an initial consultation with a community pharmacist to review appropriateness of therapy, compliance and concordance, lifestyle, and social and support issues. Control patients received standard pharmaceutical care from their community pharmacists, which included opportunistic suggestions about changes in medication or advice on lifestyle and over-the-counter (OTC) medicines. Details on the outcomes and main results of the trial are reported elsewhere.6 The objectives of the work reported here were to assess patient satisfaction with, attitudes toward, and expectations of or experience with community pharmacy in general, and to evaluate the effect of the community pharmacy–led medications management service on these. Methods In the UK, a primary care organization is the administrative unit responsible for delivery of all primary care services (eg, medical, pharmacy, dental, optical) in a defined geographical area. Nine primary care organizations in England participated in the Community Pharmacy Medicines Management Project. Patients in the study were aged 18 years or older and had a recorded history of CHD (defined as previous myocardial infarction, angina, coronary artery bypass graft, angioplasty). Patients were identified from family physician records and recruited via the family physician. Consenting patients returned their contact details to the researchers, who allocated unblinded subjects to either the intervention or control group and mailed them a questionnaire (preintervention). Reminders were sent after 2 and 4 weeks. All of the mailings included a paid reply envelope. The questionnaire included questions on patient demographics and lifestyle; satisfaction, relationships with, and expectations of the pharmacist; and most recent experience with a local pharmacy visit. The questionnaire’s content was determined by the project aims, other pharmacy service questionnaires, and the literature.6-8 A follow-up questionnaire was mailed 12 months after the intervention had started (or a similar time period for people in the control group). It was based on the baseline version, with additional questions for intervention patients about their experience with the new service. A total of 1441 (control 500, intervention 941) patients were recruited into the trial. The questionnaire included both fixed-choice questions and Likert scales to assess agreement with individual statements. Patient satisfaction was assessed by 15 statements, n


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to which participants responded on a 5-point linked scale (strongly agree, agree, neither agree or disagree, disagree, strongly disagree). The responses were cumulative, leading to an overall score between 15 and 75. Higher scores represented greater satisfaction. Full details on the development and validation of the satisfaction scale are presented elsewhere.7 The surveys were conducted between April 2002 and June 2004. Data were optically scanned into SPSS, version 11.5 (SPSS, Chicago, IL). A random sample of 10% of questionnaires was checked manually to verify data entry. Data analysis primarily used descriptive statistics. Medians (interquartile range [IQR]) were calculated for skewed continuous data, and frequencies and valid percentages (ie, the percentage of those who answered each question) were calculated for categorical data. Responses to the Likert scales were dichotomized into (1) agree and strongly agree and (2) a combined group of neither agree nor disagree, disagree, and strongly disagree. Patients’ preferences concerning elements of service that they would like to receive when visiting a pharmacy for prescription medications were analyzed using factor analysis with varimax rotation to assess any underlying main domains. Factor analysis attempts to identify a small number of underlying variables that explain the pattern of correlations (or variance) within a set of observed variables. Varimax rotation is a commonly used orthogonal rotation method that minimizes the number of variables that have high factor loadings on each factor and serves to simplify the interpretation of the factors.8,9 The internal consistency of the scales developed from these factors and the satisfaction score were assessed using Cronbach’s α statistic. Differences between intervention and control group at follow-up adjusted for baseline data were examined using multiple regression analysis.10 Groups were considered to be independent for statistical purposes, as not all individuals responded to both variables. The effect of the intervention was presented as a mean difference for the overall satisfaction score, adjusted for differences in outcomes at baseline, sex, age, and previous CHD event, as well as for cluster effects within pharmacies, general practices, and areas. The Heckman selection model was applied to test and adjust for selection bias.11 At follow-up, the χ2 test was used to compare patient agreement with a series of statements beginning, “Compared with a year ago,” across intervention and control patients. Since multiple tests were applied, a more stringent p value of less than 0.01 was used to denote statistical significance. Ethical approval for the study was given by the Multicentre Research Ethics Committee for Scotland, with confirmation by the local research ethics committee in each of the 9 primary care organization areas.


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Patient Evaluation of a Community Pharmacy Medications Management Service

Results SURVEY RESPONSE RATE AND PATIENTS’ CHARACTERISTICS

Response rates were comparable across groups at both baseline and follow-up. At baseline, 1232 evaluable questionnaires of 1441 were returned. Forty-seven patients withdrew, giving an evaluable response rate of 88.4% (1232/1394). During the follow-up period, 86 patients had died or withdrawn from the study and were not sent questionnaires. Of the remaining 1355 study participants, 1085 (80.1%) returned their follow-up questionnaire. In the following reporting of the results, the denominators are variable since they report the numbers accurately responding to each question (ie, missing values are excluded). At baseline, most respondents were older than 65 years (76%, 922/1214), male (68%, 828/1214), retired (71%, 856/1214), and white (99%, 1200/1214). The characteristics of respondents to the follow-up questionnaire were similar: 81% were older than 65 years (783/961), 69% male (661/956), 72% retired (686/956), and 99.7% white (953/956). EXPERIENCES WITH AND ATTITUDES TOWARD COMMUNITY PHARMACY

Patients’ Experience of Being Asked about Key Treatment Issues at Their Most Recent Pharmacy Visit

At follow-up, more respondents from the intervention group compared with the control group reported being asked about their lifestyle (5.2% [37] vs 2.2% [8], respectively; p = 0.02), problems with medications (11.4% [81] vs 6.2% [23], respectively; p = 0.005), blood pressure (6.2% [44] vs 2.7% [10], respectively; p = 0.014), or cholesterol (5.5% [39] vs 2.1% [8]; p = 0.014), although the absolute percentages were small. Contact with the Pharmacist at the Most Recent Pharmacy Visit

Patients were asked about their contact with the pharmacist at their most recent pharmacy visit. There were no statistically significant differences between groups (ie, spoke to pharmacist 30% [213] vs 27.9% [103], respectively). PATIENTS’ EXPECTATIONS

No item presented a statistically significant difference in preferences at the 1% level (Table 1). After factor analysis, 3 main factors were identified from the list of 19 items: pharmacist and pharmacy-related www.theannals.com

role (16 items), a wider advisory health–related role for the pharmacist (2 items), and a traditional technical dispensing role for the pharmacist (1 item) (Table 1). The first factor included items related to type of service provided by the pharmacist, pharmacy premises, and patient–pharmacist relationship. For each factor, there was high interitem correlation (Cronbach’s α between 0.79 and 0.95), confirming good internal consistency of the scales across trial groups and time (Table 2). Overall, the statements that most patients either agreed with or strongly agreed with were “The pharmacist should be knowledgeable about the treatment of heart problems” and “The pharmacist should answer my questions satisfactorily.” There was least agreement from the patients with the single statement in factor 3, “A pharmacist should only dispense prescriptions.” PATIENT SATISFACTION

Different aspects of patients’ satisfaction with their most recent pharmacy visit were assessed and a total score was calculated (Cronbach’s α intervention 0.91, control 0.90 at baseline). No substantial differences occurred between intervention and control patients at baseline (median 42.0; IQR 36– 48 in both groups). At follow-up, the overall adjusted mean satisfaction score was significantly higher for intervention patients than for control patients (46.0, IQR 40–55 and 43.0, IQR 38– 49, respectively; p < 0.01). Four individual statements showed significant difference in satisfaction at the 1% level (Table 3). EXPERIENCE OF THE MEDICATIONS MANAGEMENT SERVICE

Delivery of Service

The medications management consultation lasted for a median time of 30 minutes (IQR 25– 45). Most (98%) patients rated this as “about right.” After their initial consultation, 28 patients (4% of those seen) reported having at least one more planned consultation with their pharmacist and 61 (8%) having at least one unplanned consultation during the 12 month follow-up period. Thus, almost 90% of patients reported only a single consultation with the pharmacist. Just over a quarter of patients (26%; n = 193) said that they would have liked more planned consultations than they received and 69 (9%) would have liked further unplanned consultations. Patients who experienced the service reported receiving various recommendations from the pharmacist related to lifestyle (15%), diet (15%), prescribed medications (17%), and OTC medications (4%). Most (94%) agreed/strongly agreed that the area in which their consultation was conducted permitted private discussion of their drug therapy.


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Intervention patients were more likely to agree with the statement than control patients that, compared with one year ago, they knew more about their medications (73% vs

65%; p = 0.01). There was very little difference between the groups in self-reported understanding of the importance of taking medications as prescribed (Table 4).

Table 1. Patient Expectations at Baseline and Follow-Upa Intervention, % (n) Factor

Baseline

1. Pharmacist and pharmacy-related My pharmacist should discuss my prescribed medications with my doctor. A pharmacist could help me decide if my prescribed medications are doing what they are supposed to. The pharmacist should be knowledgeable about the treatment of heart problems. The pharmacist should explain how to take my prescription medications. The pharmacist should tell me what to do if I miss a dose. The pharmacist should tell me about possible side effects. The pharmacist should ask me questions about OTC medications when collecting a prescription. The pharmacist should ask me questions about prescribed medications when buying OTC medications. The pharmacist should make me sure I understand how to take my prescription medications. The pharmacist should talk privately with me. The pharmacist should make sure I don’t wait too long for my prescription to be completed. The pharmacist should take a genuine interest in me as a person. The pharmacist should take my concerns seriously. The pharmacist should give me the opportunity to ask questions. The pharmacist should answer my questions satisfactorily. The pharmacist should explain about my heart problems in a way that I understand. 2. A wider advisory health-related role for the pharmacist The pharmacist should give me information about my health as well as about my medications. The pharmacist should sort out any medical problems that I may be expecting. Total Nb

Control, % (n)

Follow-up

Baseline

Follow-up

p Value

68.2 (545) 76.5 (610)

61.3 (434) 65.3 (462)

64.7 (261) 73.7 (300)

53.3 (198) 60.9 (227)

0.371 0.458

91.7 (797)

87.7 (588)

88.3 (357)

85.3 (309)

0.424

60.2 (471) 68.2 (532) 84.3 (664) 50.0 (391)

58.9 (397) 69.1 (464) 84.4 (569) 48.3 (323)

58.6 (234) 68.8 (275) 82.1 (334) 51.6 (206)

54.6 (200) 64.1 (234) 80.8 (294) 44.8 (163)

0.544 0.476 0.086 0.947

72.7 (571)

68.6 (462)

69.4 (279)

69.9 (253)

0.518

83.3 (658)

85 (576)

83.9 (340)

84.6 (308)

0.939

53.9 (422) 80.4 (722)

45.7 (308) 81.8 (551)

51.7 (209) 79.3 (321)

45.9 (166) 79.7 (288)

0.171 0.791

62.7 (494) 86.3 (678) 86.9 (682) 92.4 (728) 80.2 (630)

60.1 (408) 83.1 (560) 83.3 (563) 90.8 (610) 76.3 (515)

60.4 (244) 84.1 (339) 85.2 (345) 90.3 (365) 73.2 (295)

56.4 (206) 77.2 (280) 82.3 (302) 87.8 (316) 67.5 (247)

0.039 0.685 0.751 0.813 0.563

61.2 (480)

49.7 (334)

62.2 (250)

46.1 (168)

0.043

57.8 (454)

46.3 (312)

55.6 (224)

43.5 (159)

0.407

797

610

365

316

OTC = over-the-counter. Percentages represent respondents who agree/strongly agree with each statement. b This is the maximum denominator for a particular question. However, due to missing values, this value varies by question. a

Table 2. Factor Analysis Follow-up

Baseline Factor 1 variation explained (%) mean score Cronbach’s α 2 variation explained (%) mean score Cronbach’s α 3 variation explained (%) mean score Cronbach’s α Total scale mean score Cronbach’s α n


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Intervention

Control

Pooled

Intervention

Control

Pooled

47.90 2.04 0.94

54.60 2.04 0.95

50.28 2.04 0.94

51.73 2.05 0.95

46.67 2.17 0.93

48.20 2.09 0.94

6.38 2.19 0.79

6.41 2.19 0.85

6.20 2.19 0.81

6.45 2.32 0.80

7.14 2.48 0.81

6.70 2.38 0.80

5.71 3.25

5.40 3.15

5.65 3.22

5.43 3.17

6.61 3.09

6.02 3.14

2.14 0.93

2.13 0.95

2.13 0.94

2.17 0.94

2.28 0.93

2.20 0.94


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Patient Evaluation of a Community Pharmacy Medications Management Service ATTITUDES TOWARD FAMILY PHYSICIANS AND COMMUNITY PHARMACISTS

A smaller percentage of patients in the intervention group compared with patients in the control group agreed/strongly agreed that, compared with one year ago, they would prefer to see the physician about their medications (76% compared with 85%; p < 0.01). After experiencing the service, intervention patients felt more able to ask the pharmacist questions that they would be unable to ask a physician (20% at follow-up and 11% at baseline; p < 0.01) (Table 4). Compared with a year before, intervention patients were more likely to ask pharmacists questions that they would not ask their physician, recommend to other people that

they should discuss their medications with a pharmacist, find it easier to talk with the pharmacist about their drugs and health, and ask the pharmacist questions about their medicines and health (Table 4). Discussion Patient satisfaction with, attitudes toward, and expectations of or experience with community pharmacy in general were assessed. Our results suggest that the intervention was associated with significant, positive changes in attitudes toward the community pharmacist. Patients who received the new medication management service were more satisfied with their most recent pharmacy visit compared with those in the control group and had more posi-

Table 3. Patient Satisfaction at Baseline and Follow-Upa Intervention, % (n) Statement The CP seemed to take a genuine interest in me as a person. I felt that others could listen. The CP told me how to take my prescriptions. The CP told me what to do if I missed a dose. The CP told me about possible side effects of my prescriptions. The CP gave me information about my health as well as my prescription medications. The CP asked about any overthe-counter medications I may be taking. I was able to ask the CP all the questions I wanted to. Any questions I had were answered to my satisfaction. Any medication problem I was experiencing was sorted out. My concerns were taken seriously. I could understand the information I was given. Other pharmacy staff seemed to be knowledgeable about the treatment of heart problems. I had to wait too long for my prescription to be completed. The pharmacist made sure that I understood how to take my medications. Total score, median (IQR) Total Nf

Baseline

Control, % (n)

Follow-up

Baseline

Effectb

Follow-up

95% CI

p Valuec

36.9 (281)

47.3 (168)

36.8 (148)

37.0 (122)

1.6

1.0 to 2.6

0.05

16.9 (126) 32.1 (240)

18.7 (65) 36.0 (121)

18.8 (73) 30.2 (117)

14.6 (47) 29.0 (94)

1.2 1.1

0.7 to 2.0 0.7 to 1.8

0.6 0.6

14.8 (109)

22.9 (75)

12.4 (48)

14.6 (47)

1.7

0.9 to 3.2

0.08

14.5 (107)

23.2 (76)

15.0 (58)

15.7 (51)

2.6

1.4 to 4.7